Friday, September 04, 2015

About a year ago, after Eric Duncan died at Texas Health Presbyterian Hospital in Dallas and two nurses who cared for him were hospitalized with the same disease that killed him (Ebola), Texas Health Resources got an independent committee to review what went wrong. It was like a root cause analysis, but more so: these were outside doctors and one nurse, they weren't paid, and they were given access to everything that was charted and all the folks involved in the Presby debacle.

They came to a number of conclusions: first, that education was lacking--the staff wasn't aware of what exactly to do in case of a person with Ebola coming in; second, that communication was poor--the nurse who took Mr. Duncan's health history didn't communicate verbally to the doc that he'd come from an Ebola-affected area; and third, that the fear of poor patient satisfaction scores led the doctors and nurses to rush Mr. Duncan through the ED that first time, in order to keep other patients from waiting and getting mad.

The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

Read that again. The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

I don't know what it's like in Dallas, but here in Bigton, every medium-sized hospital and most of the smaller ones have billboards touting how fast a person can be seen in their various EDs. Some of them even have big neon numbers that show the current wait times outside the hospital itself. A few even have those big neon numbers on billboards on the highways.

The entire focus of emergency-room care has become, at least in this area, about how fast you can be seen for belly pain. Or a broken arm. Or allergies. Yes, they advertise ED services for seasonal allergies. And it's all about the time it'll take for you to be seen. Come in with a head injury following a fall or a sore back that's been going on for a month? Doesn't matter--our goal is to have you back in a room in ten minutes or less and have you out the door in half an hour.

At the beginning of flu season here in Texas, that emphasis on speed, which is translated to patient satisfaction by administrators, contributed to already-stressed doctors and nurses missing a diagnosis that turned out to be fatal.

(There's a lot to be said on the communication front as well--why was the flag in the chart that the nurse filled out not enough to alert the doc? Was he, perhaps, rushed? Why the emphasis on verbally informing him of something, when the nurse might not actually see the doc face-to-face all shift because they're both busy? That'll have to wait, though.)

Let's take this down a notch. At Sunnydale General and Holy Kamole, there's a big push on to satisfy patients in every way possible. Press-Ganey cards are sent to each and every in- or out-patient within a week of their leaving the hospital or clinic, and the results are taken very seriously.

I work in a critical care unit. It's likely that the patients that I see will go on to spend a few weeks either on a floor or in rehab or both, and may or may not remember their time with me. Brain injuries tend to wipe out short-term memory. Even if they do remember the NCCU, they probably won't remember me by name. All this leads to a very minor chance that they'll be able to fill out a card that mentions me specifically.

Yet if I'm not mentioned by name by at least one patient in a year, preferably by two or three, I won't get a point on my employee review. It doesn't matter how many students or new nurses I precept, how many errors I catch, or how often my patients have good outcomes. What matters is that somebody who's stressed or ill, possibly without family support, remembers my name (perhaps weeks or months after seeing me for a day or two) and takes the time to mail back a postcard with my name on it. Missing that point can make the difference between a raise and no raise, or between a satisfactory or unsatisfactory review. It's weighted that heavily.

We no longer track how often certain nurses' patients get bedsores or UTIs or end up going back to the CCU. What we track now is how often they're praised by patients or family members.

As a result, I find myself doing all kinds of crazy shit to get people to remember me. We're not allowed to hand out the Press-Ganey cards or special-mention cards ourselves, so it's up to us to do everything possible to make ourselves stand out. Most of the time, for me, it's staying at the bedside a little longer to explain what's going on with the care plan, or the physiology of the disease we're dealing with, or why the patient is on a ventilator or has this or that tube.

Sometimes I have to sweeten family members or patients who are determined to be upset. I act as counsellor, waitress, and gofer. A lot of times, those patients or families take me away from jobs I ought to be doing just so I don't end up with a complaint--I didn't get them a cup of coffee, or something. If I have a patient I'm worried about because her neuro status is changing, I have to weigh the consequences of letting her go for another ten minutes versus the consequences of being seen as not "patient satisfaction oriented" enough.

The worst example of this happened after a patient, who was fully in command of all his faculties, took a swing at me. Only a complicated move reminiscent of the "Matrix" movies kept me from a broken skull. Afterwards, the assistant manager told me I had to go back and make nice with the guy. I told him no, that I would not, and further, that if he or any other patient ever tried to hit me again, I would be calling the cops and pressing assault charges, and maybe suing the hospital for making my work environment unsafe. I refused to reenter the room.

I got a note on my review that year that said "Jo is an excellent clinician but needs more work on her relationships with patients."

For all you folks who want to point out that service is part of nursing, and that serving is a holy and higher cause, you go right ahead. I serve every day that I work, from before the time that I punch in to whenever the job is done (whenever that is). Service to my fellow humans, though, does not mean martyrdom or risking personal injury. It certainly doesn't mean putting a patient's satisfaction scores ahead of their health or safety.

If you, Administration, want me to be a good nurse, then let me be a good nurse. Let me educate and comfort and calm. Let me commiserate and be compassionate and do all the things that I was trained to do, including catching med errors and fixing problems. Don't push the patient satisfaction side of the equation so hard that you forget what you hired me to be: the first, last, and best guardian of my patient's health and safety. Don't confuse happy people with good outcomes.

And for God's sake, and the sake of your patients, don't push my profession into waitress/hostess mode so hard that we all forget what nurses are here for.

Full time paramedic in very urban, indigent city here. Our management does satisfaction cards too. Who knows why - when you call 911, do you really expect to be "satisfied", or do you expect to be kept alive and stabilized til we hit the ER? There's actually a question in there about "satisfaction about the riding experience". Am I an Uber driver and didn't know it?

That is appalling--but not surprising, sadly. How do we begin to fix this mess? Whenever I receive a satisfaction card, I suggest that management not spend (as in waste) their money on the cards at all but rather ask their employees directly what should be done to improve their jobs. They are the ones who know. Patients aren't really in a position to evaluate the quality of their care since they simply don't have the medical background that would require.

Slightly OT, but related: When my mother died, I sent a letter to the staff (nursing home) thanking them for their kindness and thoughtfulness toward her, especially in her last days. I got an e-mail from an administrator asking for permission to notify them. I replied, "Yes, of course, it was addressed to them."

The flip side (from 30 years ago) - I worked night shift in a CCU. We were ordered to wake all patients up at night to see that they were bathed and their beds were changed. The patients were furious. Trying to convince the head nurse that the patients were upset and complaining did absolutely no good. We finally did an end run and started complaining to the physicians. That got the number of required baths down by 50%. While I do understand that day shift is a lot busier than night shift, patients needed their sleep and it was impossible on the other shift. The pendulum has swung too far in the other direction. Maybe someday the hospitals will figure out how to get it right.....

This is a powerful post. It's not right that you're judged on those patient satisfaction cards (by name, really? for people who are sick and in pain?), but this tells the rest of us to make a point of filling them out instead of ignoring them, for sure.

I'm dealing with both sides of this right now in Bigton. Do I think it's ridiculous that our reimbursement and reviews and raises depend so heavily on customer satisfaction? Yup. But our scores are sinking, so we have to do something about it. The service focus isn't going to change any time soon. So what's the answer? Not playing the game isn't an option. Sigh.

My friends and I (in our 60's) frequently wonder how this country got so stupid. These rating systems are an excellent example of stupid. The wrong things are being measured. I personally would prefer not getting a UTI than a cup of hospital coffee.

Speakng of evaluations and raises...in our unit our raises are based SOLEY on ill time. We are allowed 4%. Due to a case of shingles and a kidney stone i missed 5%...no raise. The fact that I picked up an extra 560 hours that year did not make a difference. The fact that My productivity is among the highest in the unit did not make a difference. What other profession treats their staff this way???!!!

I left hospital nursing after 15 years in CVICU, and I loved every minute. Can't do it anymore physically--thank goodness I left before the current patient satisfaction craziness. The fact that you work in a neuro unit, and manglement expects patients to remember your name, or you don't get a raise is not just sad, but criminal. I miss hospital nursing, but my work-from-home UR job doesn't expect me to put patient satisfaction above patient safety.

This a powerful, thought provoking post. I'd love to see it picked up by KevinMD's site so it gets more reads.

Jo, I wish you lived next door and could come over for a drink and bitch session. Healthcare is breaking my heart and spirit (I'm a PT). I like what I do and I think it's important but I hate that it's become so much about making money. And I hate even more that I don't have the balls to go to my administrator and say "I'd like to get paid less so we could focus more on patient care than on reimbursement"

I still remember my first mention in a Thank You card from a patient- my name was mentioned because I gave the patient a blanket from the blanket warmer. That was the only mention of a specific care episode in the letter. That same shift I caught a patient bleeding post bowel surgery and we got him back to theatre before he crashed, but there was no card from that patient or family.

Patients and families definition of good care is definitely not the same as ours.

Great post! I blame Burger King and "have it your way" mentality. And now that the Feds have brought satisfaction into the matrix (where it's as heavily weighted as outcomes!) it can and does effect reimbursement from Medicare it's only going to get worse. No wonder why so many amazing, talented, brilliant, caring nurses are leaving the bedside!

I believe patient satisfactions scores should be tossed in an ED. Sure we could see everyone in a timely manner we did not have to waste time on: 1) drug seekers 2) people who use the ED for clinic issues or 3) returners who never follow thru with medical advice.

My job is to treat and street and I do not care if you like me or are even satisfied. I strive to provide competent care in a somewhat timely manner.

"Speakng of evaluations and raises ... What other profession treats their staff this way???!!!"

My paramedic job here doesn't really do raises ever. I got one, not sure how, and I've been told that it's the first one ever given in years. Best bet at this company is to leave and rehired at a higher rate of pay, because there are new hires here that make more than long-standing employees.

IMO, the best line in this column is: "Don't confuse happy people with good outcomes." That is the heart of the problem: people measure one thing and use the measurement for an unrelated purpose. I am an expert in measurement (yes, there is such a thing), and I teach people how to do research so that the results are valid. I could give you a gajillion examples of one thing being measured, then the scores being used for a different purpose. In your case, satisfaction is being used to judge the quality of nursing care or job performance. Here is another example: public school achievement tests being used to judge the quality of schools and the quality of teaching. Other examples have been given in the above comments. Validity in measurement must include the idea of the scores being adequate and appropriate for the purpose they are supposed to serve. This important idea is omitted by people who don't know sh*t about measurement but have the power to make those decisions.

If they want to know about the quality of nursing care, they need to have experienced nurses doing qualitative assessments by direct observation of the nurses whose care is being judged. There needs to be a consistent way of determining whether quality care has been delivered. In other words, there has to be some agreement among nurses about what "nursing care" is, what characteristics are considered "good nursing care," what details are considered "bad nursing care," etc. If another experienced nurse can come in and make the same judgment about the quality of care using the ideas that have been established as indicators of quality care, then there is evidence of consistency in the measurement.

Most job performance evaluation systems suck. I helped to develop a system of performance evaluation for a state government, and it has been used for many years. It takes work to do performance evaluation well, and people who are placed in charge of performance evaluation generally don't have time, motivation or adequate training for the task. Generally most supervisors get an idea of whether they think the employee has done a good job, bad job, or so-so job in the last year, then they force the scoring to fit that Gestalt impression. To overcome the subjectivity of the system, some organizations try to find "objective" measures (which generally don't exist if you are asking humans to generate any kind of ratings) to complement the performance evaluation. Then some bing-bong administrator comes up with the bright idea, "Hey, let's use these patient satisfaction scores!" They ignore the fact that the most dissatisfied people are more likely to send in their ratings, and the administrators accept those ratings as gospel. Instead, they should see the ratings as a limited view from a few sick people who might have some kernel of truth in their story that could point to one possibility for quality improvement.

Wanted to tell you: your blog influenced me today. I was filling out a patient satisfaction form on my mother's behalf after her stint in a rehab hospital. I gave positive feedback and mentioned as many nurses and therapists as I could remember by name.

Sorry. You should have pressed charges. I work in the ED and sent two "patients" to jail last year. My rules are the same as the police: I go home safe. I have ZERO tolerance for violence against nurses and other staff. Assault on a nurse is now a felony in Colorado.